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News

Mar 30, 2017

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What’s next for the ACA?

by | Mar 30, 2017

Health

Last Friday, Speaker of the House Paul Ryan pulled the American Health Care Act (AHCA) from the floor, sparing his members a recorded vote on a flawed bill, and sparing the country the consequences of advancing a proposal that would have resulted in the loss of health insurance coverage for 24 million Americans.

It was reported this week that Ryan, the Freedom Caucus and the White House held closed-door conversations about how and whether they will take another run at the thorny problem of health reform. Given the challenges of finding a middle path that will satisfy ultraconservatives and moderates and win the approval of the Senate, this seems a nearly impossible task.To paraphrase the President, “health care is complicated.”

Whether or not Congress comes up with a new proposal, the future of the Affordable Care Act (ACA) is still an open question. The President has said again and again that the ACA will ultimately “explode.” While there is no evidence that this will happen, there are certainly steps the administration can take that will make that prospect more (or less) likely:

Cost sharing reductions and the impact on the market – In 2014, Congress filed a lawsuit, House of Representatives v. Price (originally, House v. Burwell), challenging the Obama administration’s payments to insurers to support cost sharing reductions (CSR) that were created by the ACA. The plaintiffs argued that the funds to support the program were never appropriated by Congress. CSR helps to make insurance more affordable by reducing out-of-pocket costs for those who earn under 250 percent of the Federal Poverty Level who receive an ACA premium subsidy through a health insurance exchange.

Without a Congressional appropriation, insurers are responsible for bearing the cost of CSR, a total estimated expense to insurers participating in exchanges of $130 billion over 10 years. If required to bear this burden, insurers likely would either stop participating in exchanges or raise health insurance premiums to cover their costs. Either choice would undermine the stability of the exchanges.

The lower court judge in the CSR lawsuit ruled in Congress’s favor, but allowed CSR payments to insurers to continue pending the outcome of an appeal. The appeal is pending before the federal Circuit Court in Washington D.C. Unknown at this point, is whether the Trump Administration will defend the lawsuit; typically it would be the job of the administration to defend a suit against an executive agency – in this case, the U.S. Department of Health and Human Services. Some beneficiaries of CSR have filed a motion to intervene in the suit so that they can defend the payment structure in the event the Trump Administration does not. The intervenors’ motion was filed in December.The bottom line: If the plaintiffs lose, Congress will take action to eliminate CSR altogether, harming millions of lower-income exchange enrollees. Meanwhile, insurance companies will pass on the cost of CSR to their customers, raising the cost of insurance in the individual market, or insurance companies will withdraw from the exchanges in which they participate.

Failure to enforce the individual mandate will increase costs — The very first executive order signed by President Trump included broad language ordering federal agencies to “ease the regulatory burdens” of the ACA. There have been questions since regarding what this means, but what is clear is that the IRS is relaxing enforcement of the individual mandate. The mandate is an essential component of the ACA, and while the penalties have been criticized as being too low to bring people in to the insurance market, relaxation of their enforcement is likely to undermine participation in insurance.Sicker people will participate in insurance because they need care, and younger healthier people will be even more likely to stay out of the market.This kind of adverse selection drives up health insurance costs and is unsustainable over time.

Regulatory changes that limit exchange enrollment — The first set of ACA regulatory changes, proposed after meetings with the nation’s insurance companies, has already gone through a 30-day comment period.  Among other things, the proposed changes would shorten the open enrollment period to six weeks and make it harder for people to qualify for special enrollment periods. What effect will this have?  A shortened open enrollment period may well pose particular problems in Colorado where IT and customer service infrastructure may not be able to keep up with significantly increased workloads occasioned by a compressed timeframe. In addition, requiring 100 percent of people claiming eligibility for a Special Enrollment Period to prove rather than certify their eligibility, will make it more difficult for them to apply for and enroll in insurance.

SEP’s are available when personal circumstances change — for example, upon the loss or change of a job or as a result of a change in family circumstance such as divorce, marriage, birth or adoption of a child. What we know about application processes is that the more burdensome they are the less likely people are to complete them. Insurance companies claim people are falsely claiming eligibility under SEPs; the evidence does not support that claim. And, according to the Urban Institute, only about 15 percent of people eligible for an SEP enroll in insurance outside of open enrollment periods. We should be making it easier, not harder, for people to enroll.

So, what can we do? Here are a few ideas:

Don’t let Congress or the White House destabilize insurance markets — We need to let our Congressional delegation know that we should build on the ACA, not tear it down and, while we acknowledge the ACA needs work, its structure is sound. The CSR lawsuit, proposed regulations and the failure to enforce the individual mandate hurt all of us by destabilizing the insurance market and increasing premium costs.

Ensure Colorado takes advantage of state flexibility to strengthen the marketplace — We should oppose regulatory changes that undermine the insurance market and use whatever flexibility the state may have when new regulations are approved, to keep our marketplace strong. For example, if the open-enrollment period is limited to just six weeks, we should explore whether Colorado may seek a waiver to extend that period if we are unable to manage a high volume of enrollments within such a short timeframe.

Fix the “family glitch” — The so-called family glitch prevents family members of people with employer sponsored health insurance from being eligible for premium assistance for individual coverage on the exchange. Allowing family members to be eligible for the exchange would bring more people into coverage and increase the number of young and healthy people in Connect for Health Colorado and other exchanges.The family glitch has been a known problem since before the ACA was implemented.It continues to keep people out of coverage.We should fix it.

CCLP will keep you posted on further state and Congressional developments and opportunities to take action in Colorado through our communications products and our Facebook and Twitter feeds.

-By Elisabeth Arenales

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HEALTH:
HEALTH FIRST COLORADO (MEDICAID)

Health First Colorado is the name given to Colorado’s Medicaid program. Medicaid provides public, low-cost health insurance to qualifying adults and children. It is an entitlement program funded by the federal, state, and county governments and is administered by counties in Colorado. Those who are required to pay must pay a small co-pay when receiving certain health care services.

State Department: Department of Health Care Policy and Financing

Eligibility: Most adults 18 to 64 are eligible for Medicaid in Colorado if their household income is at or below 133% of the federal poverty limit (FPL). Pregnant women are eligible with incomes of up to 195% FPL, while children under 18 may be eligible if the live in a household with income at or below 142% FPL. Some adults over 65 may also be eligible for Medicaid.

Program Benefits: Through Medicaid, low-income Coloradans are eligible for a range of health care services at little to not cost. Services provided include doctors visits, prescription drugs, mental health services, and dental care. Co-pays for certain individuals may be needed for certain services.

Program Funding and Access: Colorado funds our Medicaid program through state and federal dollars. Medicaid is an entitlement program, which means that all who are eligible for Medicaid can access the program, regardless of the funding level in a given year. This does not mean that it is always easy to access Medicaid, even when eligible. And since the program is administered by counties, funding levels for county staff and other administrative roles can make it easier or harder for Coloradans to access the program. On top of this, not all medical providers accept Medicaid which limits the ability of Coloradans to seek health services even if enrolled, such as if the nearest provider is a 2+ hour drive away.

Note: This data is from before the pandemic and does not reflect changes in enrollment rules during the COVID-19 pandemic and public health emergency.

Statewide Program Access 2015-19: Over the study period of this report, an average of 89.0% of the population at or below 133% of FPL (i.e., the population who is likely to be eligible for Medicaid) were enrolled in Medicaid in Colorado.

FOOD SECURITY:
SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM (SNAP)

The Supplemental Nutrition Assistance Program or SNAP helps low-income Coloradans purchase food by providing individuals and families with a monthly cash benefit that can be used to buy certain foods. SNAP is an entitlement program that is funded by the federal and state governments and administered by counties in Colorado.

State Department: Department of Human Services

Eligibility: Currently, Coloradans qualify for SNAP if they have incomes below 200% FPL, are unemployed or work part-time or receive other forms of assistance such as TANF, among other eligibility criteria. Income eligibility for SNAP was different during the study period of this report than today—it was 130% FPL back in 2019 for example. The US Department of Agriculture uses the population at or below 125% FPL when calculating the Program Access Index (or PAI) for SNAP. We follow this practice in our analysis despite Colorado currently having a higher income eligibility threshold.

Program Benefits: SNAP participants receive a monthly SNAP benefit that is determined by the number of people in their household and their income. Benefit amounts decrease as income increases, helping households avoid a sudden loss of SNAP when their incomes increase, even by a minor amount. Benefits are provided to an Electronic Benefit Transfer (EBT) card that can be used to purchase eligible food items, such as fruits and vegetables; meat, poultry, and fish; dairy products; and breads and cereals. Other items, such as foods that are hot at their point of sale, are not allowable purchases under current SNAP rules.

Program Funding and Access: SNAP, like Medicaid, is a federal entitlement program. This means that Colorado must serve any Coloradan who is eligible for the program. As such, funding should not be a limit to how many Coloradans can be served by the program. However, funding for administration of SNAP at the state and county level can limit the ability of county human service departments to enroll those who are eligible. Other program rules and administrative barriers can make it difficult for Coloradans to receive the benefits they are legally entitled to receive.

Statewide Program Access 2015-19: Over the study period of this report, an average of 61.1% of the population at or below 125% of FPL (i.e., the population who is likely to be eligible for SNAP) were enrolled.

FOOD SECURITY:
SPECIAL SUPPLEMENTAL NUTRITION PROGRAM FOR WOMEN, INFANTS AND CHILDREN (WIC)

The Special Supplemental Nutrition Program for Women, Infants, and Children, also know as WIC, provides healthcare and nutritional support to low-income Coloradans who are pregnant, recently pregnant, breastfeeding, and to children under 5 who are nutritionally at risk based on a nutrition assessment.

State Department: Department of Public Health and Environment

Eligibility: To participate in WIC you must be pregnant, pregnant in the last six months, breastfeeding a baby under 1 year of age, or a child under the age of 5. Coloradans do not need to be U.S. citizens to be eligible for WIC. In terms of income, households cannot have incomes that exceed 185% FPL. Families who are enrolled in SNAP, TANF, Food Distribution Program on Indian Reservations (FDPIR), or Medicaid are automatically eligible for WIC. Regardless of gender, any parents, foster parents, or caregivers are able to apply for and use WIC services for eligible children.

Program Benefits: WIC provides a range of services to young children and their parents. These include funds to purchase healthy, fresh foods; breastfeeding support; personalized nutrition education and shopping tips; and referrals to health care and other services participants may be eligible for.

Program Funding and Access: WIC is funded by the US Department of Agriculture. The state uses these federal funds to contract with local providers, known as WIC Clinics. In most cases, these are county public health agencies, but that is not the case in all Colorado counties. Some WIC Clinics cover multiple counties, while others are served by multiple clinics. Private non-profit providers are also eligible to be selected as a WIC Clinic.

Statewide Program Access 2015-17: Between 2015 and 2017, an average of 52.2% of the population eligible for WIC were enrolled in the program in Colorado.

Financial Security:
Colorado Works

Colorado Works is the name given to Colorado’s program for Temporary Assistance to Needy Families or TANF. It is an employment program that supports families with dependent children on their path to self-sufficiency. Participants can receive cash assistance, schooling, workforce development and skills training depending on the services available in their county.

State Department: Department of Human Services

Eligibility: In general, Coloradans are eligible to enroll in TANF if they are a resident of Colorado, have one or more children under the age of 18 or pregnant, and have very low or no income. For example, to be eligible to receive a basic cash assistance grant through TANF, a single-parent of one child could not earn more than $331 per month, with some exclusions—and would only receive $440 per month (as of 2022). That said, there are other services provided by counties through TANF that those with incomes as high as $75,000 may be eligible for. In addition to these, participants in TANF are required to work or be pursuing an eligible “work activity” or work-related activity. Any eligible individual can only receive assistance if they have not previously been enrolled in TANF for a cumulative amount of time of more than 60 months—this is a lifetime limit that does not reset. Counties may have additional requirements and offer benefits that are not available in other counties in Colorado.

Program Benefits:  While the exact benefits that one is eligible for under TANF can vary, all qualified participants are eligible to receive a monthly cash payment, call basic cash assistance. Other than cash assistance, counties are have a lot of choice in how to use their TANF funding; generally a use of TANF funds is appropriate so long as it advances one or more of the four purposes of the program: (1) provide assistance to needy families so that children can be cared for in their own homes or in the homes of their relatives; (2) end the dependence of needy families on government benefits by promoting job preparation, work, and marriage; (3) prevent and reduce the incidence of out-of-wedlock pregnancies; and (4) encourage the formation and maintenance of two-parent families.

It is important to note that those eligible for TANF are also eligible for many of the other programs we’ve included in this report, such as SNAP, Medicaid, and CCCAP.

Program Funding and Access: Colorado funds its TANF program through funds received from the federal government through the Temporary Assistance for Needy Families block grant. Most of the federal funds are allocated by the state to counties, which are required to provide a 20% match of state funding. Federal and state rules allow the state and counties to retain a portion of unspent funds in a TANF reserve.

Statewide Program Access 2015-19: Over the study period of this report, an average of 50.7% of the population at or below 100% of FPL (i.e., the population who is likely to be eligible for TANF) were enrolled in TANF in Colorado.

EARLY LEARNING:
COLORADO CHILD CARE ASSISTANCE PROGRAM (CCCAP)

The Colorado Child Care Assistance Program provides child care assistance to low-income families and caregivers living in Colorado in the form of reduced payments for child care. It is a program funded by the federal, state, and county governments and is administered by counties in Colorado. The share owed by parents/caregivers is determined on a sliding scale based on the family’s income.

State Department: Department of Early Childhood Education

Eligibility: Counties set eligibility for families separately, but must serve families with incomes at or below 185% of the Federal Poverty Limit. Families accepted to the program are no longer eligible once their income exceeds 85% of the state median income. Parents or caregivers must be employed, searching for work, or engaged in another approved activity to be eligible for CCCAP. Parents and caregivers enrolled in Colorado Works (Temporary Assistance to Needy Families or TANF) or in the child welfare system are also eligible to participate in CCCAP. Generally, CCCAP serves families with children under 13, although children as old as 19 may be eligible under certain circumstances.

Program Benefits: If a family is eligible for CCCAP and has income, they may likely have to pay a portion of their child’s or children’s child care costs each month. The amount that families owe is based on their gross income, number of household members, and the number of children in child care in the household. As such, households tend not to experience a benefit cliff with CCCAP when they see their incomes increase

Program Funding and Access: Colorado funds the CCCAP program using federal dollars it receives from the Child Care and Development Block Grant program. The state allocates federal and state funds to counties using a formula that takes into account factors like current caseloads and the number of eligible residents. Assistance is available until the county’s funds are spent, so the number of families that can be served is often a function of how much funding is available and the income and composition of the household that applies. It is not uncommon for counties to overspend or underspend their allocations of funds. The state reallocates unspent funds from counties who underspent to those who overspent. While underspending could indicate a problem with the way a county administers its CCCAP program, it could just as likely be a sign that there are few providers in the county who participate in CCCAP—or a lack of providers generally.

Statewide Program Access 2015-19: Over the study period of this report, an average of 10.8% of the population at or below 165% of FPL and younger than age 13 (i.e., the population who is likely to be eligible for CCCAP) were enrolled in CCCAP.

Housing:
HUD rental assistance programs

The US Department of Housing and Urban Development (HUD) has three housing assistance programs that we look at together: Housing Choice Vouchers (Section 8), Project-based Section 8, and Public Housing. In Colorado, these programs provided assistance to over 90% of the households who received federal housing assistance from all HUD programs. Through federally funded, local or regional public housing agencies (PHAs) are the agencies that administer these programs, through not all are available in all counties. These are not the only programs available in Colorado that assist households afford the cost of housing, such as units funded through federal and state tax credit programs.

State Department: Department of Local Affairs

Eligibility: Generally, households with incomes under 50% of the area median income (AMI) of the county they live in are eligible for these rental assistance programs, although PHAs have discretion to select households with incomes at higher percentages of AMI. That said, HUD requires that 75% of new vouchers issued through the Housing Choice Voucher/Section 8 program in a given year are targeted to households with incomes at or below 30% of AMI. PHAs are also able to create criteria that give priority to certain types of households who are on waiting lists for these programs.

Program Benefits: These rental assistance programs help households afford the cost of housing by reducing their housing costs to around 30% of their household income. In the case of the Housing Choice Voucher program, the PHA pays the voucher holder’s landlord the remaining portion of the rent.

Program Funding and Access: Funding and access are both challenges for these rental assistance programs. In addition to limitations on the number of public housing units or housing vouchers a PHA can manage or issue, lack of funding compared to the need constrains the ability of PHAs to assist low-income households. In 2020, Coloradans were on waitlists for Housing Choice Vouchers for an average of 17 months. Waitlists also exist for the other rental assistance programs.

Statewide Program Access 2015-19: Over the study period of this report, an average of 21.1% of renter households with incomes at or below 50% AMI (i.e., the population who is likely to be eligible for HUD rental assistance programs) were living in subsidized housing.